Nedlac Framework Agreement on a National Prevention and Treatment Plan for Combating HIV/AIDS
6. TREATMENT OF OPPORTUNISTIC INFECTIONS
6.1 The parties recognise that evidence exists that people living with HIV/AIDS have been turned away from healthcare facilities and that this practice must be abolished and that all people must be treated with dignity and respect for human rights in all our health facilities.
6.2 The parties recognise that all our people living with HIV/AIDS must be provided with the continuum of care which includes:
6.2.1 support and ongoing counselling including information and advice about accessing social grants;
6.2.2 aggressive management of HIV related opportunistic infections and management of other STI’s;
6.2.3 preventive/prophylactic care – stopping disease before it develops ( eg TB and PCP);
6.3 The parties agree that no person should be sent away from hospital or a healthcare institution and not treated because of their HIV status.
6.4 Given the critical importance of drugs dealing with infections such as meningitis, oral thrush, TB and pneumonia, the parties agree to the development of an action plan to:
6.4.1 Distribute the Department of Health’s Guidelines on the Treatment of Opportunistic Infections as appropriate to every private and public sector nurse and doctor in South Africa, by 2 April 2003;
6.4.2 Train cluster-teams of health care workers to manage all major opportunistic infections. At every facility a team of people is responsible for health care. The size of the team may vary depending on local resources, but effective training will be based on the education of teams, this will include a nurse, midwife, doctor, pharmacist / pharmacist assistant, lab technician, administrator, radiologist, specialist physician and counsellors;
6.4.3 Improve the identification of TB and DOTS treatment, through a joint campaign to promote greater awareness of TB and of the prevention and treatment of TB, and greater adherence to treatment for TB;
Increase public awareness and knowledge of systems for
the evaluation and certification of traditional medicine and complimentary medicine; and
6.4.5 Government has already made a commitment to the universal right to treatment of opportunistic infections. However, this requires partnerships to ensure better drug supply to clinics, training of health professionals in accordance with existing policies, and systems for monitoring capacity, quality of care and access.
7. ANTI-RETROVIRAL TREATMENT
7.1 The UNGASS agreement recognises that care and support should include prevention and treatment of opportunistic infections and the "effective use of quality-controlled antiretroviral therapy in a careful and monitored manner". It commits signatories to develop national strategies to be developed by 2003 to strengthen health care systems and address factors affecting the provision of HIV-related drugs including antiretroviral drugs.
The parties recognise the importance of the provision of ARV treatment as an important component of a NPTP.
There will be an engagement between the Nedlac constituencies and the joint health and finance committee that will inform the constituencies of the terms of reference of the committee, brief the constituencies on its work to date and allow the constituencies to make input to the committee.
[ Immediately after the release of the report of the joint finance and health department committees, which will be completed in February 2003, the parties commit to engaging on proposed targets and resource needs for supporting the implementation of a public sector ARV programme. ]
The parties recognise the WHO Guidelines for a Public Health Approach on Scaling Up Anti-retroviral Therapy in Resource Limited Settings (April 2002), the Bredell Consensus Statement on the Imperative to Extend Access to Anti-retroviral Medicines for Adults and Children with HIV/AIDS in South Africa (November 2001) and the HIV/AIDS Clinicians Society Clinical Guidelines on Anti-Retroviral Therapy in Adults and children (June 2002).
There are several challenges to the implementation of a public sector anti-retroviral treatment programme. These include:
7.6.1 Training patients, nurses and doctors on the importance of adherence and side-effect management;
7.6.2 Training public sector health professionals on the use of these drugs;
7.6.3 Providing and strengthening the public health infrastructure;
7.6.4 Entering into partnerships with the private sector;
7.6.5 Reducing the costs of ARVs and diagnostics; and
7.6.6 Establishment of an effective pharmaco-vigilance system.
7.7 The parties agree that each of these challenges has a solution and propose that they be addressed through systematic training and public education and commitment of the appropriate resources.
7.8 To give effect to the commitments made in paragraphs 7.1 to 7.6 the Nedlac parties will engage each other after studying the report of the task team that is due in February 2003. The parties recognise accept/agree that this engagement is urgent and will aim to complete it and make recommendations on ARV programmes by April 2003.
Pending the report of the government technical task team the constituencies agree to work together nationally, continentally and globally to advance the agenda of affordable access to treatment for all, including ensuring the use of voluntary and compulsory licensing on medicines and key diagnostic tools. Whilst this agenda will apply to all medicines, in this context, attention will be paid to the interventions to deal with the totality of HIV/AIDS related illnesses.
[The parties further commit that this effort will be carried out within the parameters of South African law and in accordance with our country’s international obligations; ]
7.9 In particular:
7.9.1 Organised Labour commits to train 3 000 shop stewards to partake in support for people on treatment, which shall include home visits, promotion of openness in the workplace and counselling of fellow-workers to ensure that a caring environment is created;
7.9.2 Organised Labour commits to support efforts to raise funds for the National Prevention and Treatment Fund, from local and international donors;
7.9.3 [ The Business Sector undertakes to provide treatment for people living with AIDS, through provision of treatment to employees working at companies employing more than 300 workers, and to contribute to the National Prevention and Treatment Fund a sum of RXXX annually. Nedlac parties to agree sum to be set; ]
7.9.4 Government commits to supporting local production of anti-retroviral medicines.
7.9.5 [ Government commits to underwriting and financing the phased programme of anti-retroviral provision, in partnership with donor agencies; and ]
7.9.6 The parties commit to social mobilization aimed at breaking down stigma, providing accurate information about treatment and creating a social climate that encourages adherence to treatment; and
7.9.7 Community commits to engage in community preparedness programmes that aim to provide treatment literacy, prevention information for people with HIV, and information on human rights as widely as possible, but initially particularly targeted at the treatment sites.
7.10 The constituencies recognize that health and treatment education is essential and must be strengthened and coordinated.
7.11 Therefore the parties agree to the launch of a National Prevention and Treatment Literacy Programme. To this end, organised labour and community organizations agree to raise R10m for this purpose, through National Big Walks, and other fund-raising activities.
8. CARE AND SUPPORT
8.1. The UNGASS agreement endorsed national strategies to provide a supportive environment for orphans and children infected and affected by HIV/AIDS and said these should be developed by 2003 and implemented by 2005 and should cover the provision of counselling and psychosocial support, ensure enrolment in school and access to shelter, good nutrition, health and social services and protection from all forms of abuse, violence and loss of inheritance.
8.2 Therefore the parties agree to develop further measures to enhance care and support for their families, care givers and particularly orphans of HIV positive persons. The parties intend to finalise these measures by March 2003.
8.3. Organised labour commits to mobilize its members at local level to assist and support orphans and vulnerable children with access to schooling and other basic necessities and to encourage the adoption of orphans.
8.4. The parties agree to the further expansion of the community home-based care programme to provide appropriate care, including palliative care, to those in need. This requires collaboration between Government, NGOs and civil society in general.
The Department of Social Developing is already doing work to review the social grant system to provide adequate services, especially for orphans and children in distress.
8.6. The Partnership between Government, Business, Labour and organisations of people living with HIV/AIDS, including the National Association for People Living with HIV/AIDS (NAPWA) is important to ensure that the services provided to People Living with HIV/AIDS are appropriate. This includes reviewing appropriate care and support interventions, improving access to services, and providing drug literacy workshops to highlight the need for adherence to treatment regimens.
9.1 The parties agree that SANAC be primarily responsible for monitoring the progress and implementation of the framework agreement.
9.2 The parties agree that to ensure the effectiveness of SANAC in terms of the monitoring of the agreement, the proposed restructuring of SANAC needs to ensure that it becomes more representative, including in terms of the representation of the Nedlac constituencies and all relevant stakeholders and more transparent.
9.3 The parties agree that the strengthening of SANAC in terms of capacity, skills and resources is essential to meeting the challenge of HIV/AIDS.
9.4 The parties agree that while the restructuring of SANAC is finalised, the Nedlac task team will continue to play a role in the monitoring of the implementation of this agreement.
9.5 The parties recognise the establishment of the SANAC Trust Fund as a significant step forward in the restructuring of SANAC and agree to lend their support the Fund.
10. ADDITIONAL POINTS
10.1 [(C) Prior to finalisation of Framework agreement, but after negotiations between constituencies, NEDLAC hold a workshop with other key sectors (to be identified by constituencies) to solicit buy-in to the plan before its official launch on December 1st 2002.]
10.2 (L) The concept of organisations and institutions being able to declare themselves as "AIDS ready" should be promoted through a certification process.
10.3 ADDITIONAL NOTES from LABOUR: NEED TO HAVE MEASURES DEALING WITH THE FOLLOWING
10.3.1 NUTRITIONAL SUPPORT
10.3.2 AVAILABILITY OF STATE DISABILITY SUPPORT GRANTS
FOSTER GRANTS FOR PEOPLE WITH HIV AND THEIR CHILDREN
10.3.3 ID PAPERS FOR ORPHANS
10.3.4 STRENGTHENING CARE AND SUPPORT SERVICES
MEASURES TO DEAL WITH DISCRIMINATION
10.3.5 ADDITIONAL INFRASTRUCTURE REQUIREMENTS
10.3.6 REGULATION OF TESTING
10.3.7 MORE CONCRETE TARGETS RE TB CAMPAIGN]
11. DELETED SECTIONS
[ (L) This Framework Agreement sets out the principles on which a coordinated, comprehensive and united response is based, and provides for an anti-retroviral treatment pilot phase. ]
11.2 [ (L) This Framework Agreement constitutes one element of a series of agreements we envisage. These further agreements contemplated will deal with operational issues in more detail, and will build on the results of the pilot phase to provide increasing treatment in a phased manner. ]
12.1 [Although the HIV/AIDS challenge has not been defeated, existing initiatives in response to the HIV/AIDS challenge include: ]
[The parties agree that these initiatives will be supported, strengthened and enhanced by the agreement, and where necessary, gaps, weaknesses and shortcomings in these initiatives will be addressed jointly by the parties in a cooperative spirit. ]
12.3. [The parties recognise the centrality of eradicating poverty to any successful strategy to combat the spread of HIV and to defeat the challenge of HIV /AIDS. ]
[The parties recognise the centrality of eradicating poverty to any successful strategy to combat the spread of HIV and to defeat the challenge of HIV /AIDS. ]
13. THE PRINCIPLES ON WHICH THE PARTIES UNITE TO DEAL WITH HIV/AIDS
13.1.1 ( (G) The statement also clearly expressed the view that HIV causes AIDS, and that this belief forms the basis for interventions. However, the media still expresses doubts as the government stance on the causality of AIDS.)
13.1.2 ( (C) This statement recognizes that treatment and prevention strategies go hand in hand, and specifically promises:
13.1.3 ( (G) The statement further emphasizes:
18.104.22.168 The importance of ensuring awareness in relation to HIV and AIDS;
22.214.171.124 STI management and treatment;
126.96.36.199 The Vaccine Initiative;
188.8.131.52 Care and support interventions;
184.108.40.206 Anti-retrovirals as part of a comprehensive treatment;
220.127.116.11 Broader social issues related to the combating of HIV and AIDS and other preventable illnesses;
13.13.7 The importance of monitoring, research and surveillance;
18.104.22.168 The importance of the need for a statistical framework for ensuring accurate data;
22.214.171.124 The role of the International AIDS Panel;
126.96.36.199 The building of partnerships at local level, with health practitioners and at international level;
188.8.131.52 The role of key structures such as South African National AIDS Council (SANAC) and of government.);
13.2.4 ((L) Provision of anti-retroviral drugs in accordance with international standards, on a phased basis; )
13.2.5 ((L) The introduction of a pilot phase for treatment, during which anti-retroviral drugs will be provided on a monitored basis, and as a means to provide practical experience on the infrastructural, educational, social and financial infrastructure required for a wider programme of treatment; )
13.3 ( (C) The parties agree to a specific commitment in the Framework Agreement to the following principles:
Recognition and prioritization of vulnerable groups in access to information, prevention, treatment and care (specifically women, people with disabilities, gay men, children and refugees);
Immediate policy implementation as a principle according to a plan and with allocation of sufficient resources; and
Community mobilization around agreed prevention and treatment targets.
14. VOLUNTARY COUNSELLING AND TESTING
(a) [The Business sector will ensure that workers at all workplaces employing more than 100 workers have access to time off from normal work to attend voluntary counselling and testing programmes run either by, or in conjunction with a recognised trade union, or an agency accredited for this purpose, and will encourage companies employing fewer than 100 workers to set up joint programmes and to jointly finance such, to publicise the availability of VCT facilities at community level ];
(b) The Business Sector will ensure [proposals to be added here];
14.1.1 (C) Every attempt should be made to avoid wasteful duplication of effort and energy. Any initiatives agreed upon must be focused and effective, with predetermined outcomes.
15 ANTI-RETROVIRAL (ARV) TREATMENT
15.1.1 (C) The (community constituency proposes) parties agree that (the Framework Agreement identify the need for a) there should be greater collaboration in terms of research (agreement with) between academic and medical institutions that identifies important areas for research where institutions can maximise the impact of their collaboration. For example, there is a need to conduct research into drug interactions between medicines used for HIV/AIDS by people who have other disabilities or illnesses requiring medication.
15.1.2 ((C) With regard to 5.4.3 we propose that the Government, Business and Labour constituencies make a commitment to negotiations with pharmaceutical companies and the use of compulsory licensing a part of the framework agreement. Voluntary licenses should be requested on essential anti-HIV medicines (for ARVs and OIs) immediately, as well as for key diagnostic tools. In this regard we draw the attention of the other Nedlac constituencies to the powers held by government to reduce the price of medicines and diagnostic tools, and particularly to s4 of the Patents Act (57 of 1978) which reads:
"A patent shall in all respects have the like effect against the State as it has against a person: Provided that a Minister of State may use an invention for public purposes on such conditions as may be agreed upon by the patentee, or in default of agreement on such conditions as are determined by the Commissioner on application by or on behalf of such Minister after hearing the patentee.")
15.1.3 [To enter into negotiations with pharmaceutical companies and the use of compulsory licensing as part of the framework agreement. Voluntary licenses should be requested on essential anti-HIV medicines (for ARVs and opportunistic infections) immediately, as well as for key diagnostic tools;]
16. REVIEW MECHANISM
((B) It is believed that this can only be considered once it has been determined exactly what needs to be done under the auspices of NEDLAC. It is not possible to consider the merits or design of a review mechanism before it has been determined what needs to take place and, consequently, monitored.)
17. ANTI-RETROVIRAL TREATMENT
17.1. (L) The parties recognize that a [National Prevention and Treatment Plan] will have very significant resource implications, but will also bring about significant cost and social savings. Most importantly, an effective plan will prevent millions of infections and avert millions of deaths.
17.2 ((L) The parties endorse the commitment set out in the Abuja Declaration which states:
"WE COMMIT OURSELVES to take all necessary measures to ensure that the needed resources are made available from all sources and that they are efficiently and effectively utilised. In addition, WE PLEDGE to set a target of allocating at least 15% of our annual budget to the improvement of the health sector. WE ALSO PLEDGE to make available the necessary resources for the improvement of the comprehensive multi-sectoral response, and that an appropriate and adequate portion of this amount is put at the disposal of the National Commissions/Councils for the fight against HIV/AIDS, Tuberculosis and Other Related Infectious Diseases." (Emphasis in original))
17.3 [(L, C) The parties agree to a programme of progressively scaling up access to ARV treatment, over a ten-year period. In this respect we endorse the WHO Guidelines for a Public Health Approach on Scaling Up Anti-retroviral Therapy in Resource Limited Settings (April 2002), the Bredell Consensus Statement on the Imperative to Extend Access to Anti-retroviral Medicines for Adults and Children with HIV/AIDS in South Africa (November 2001) and the HIV/AIDS Clinicians Society Clinical Guidelines on Anti-Retroviral Therapy in Adults (June 2002).]
17.4 (L, C) There are several challenges to the scaling up of anti-retroviral treatment. These include:
17.4.1 Training patients, nurses and doctors on the importance of adherence and side-effect management;
17.4.2 Training public sector health professionals on the use of these drugs;
17.4.3 Providing and strengthening the public health infrastructure;
17.4.4 Entering into partnerships with the private sector; and
17.4.5 Reducing the costs of ARVs and diagnostics.
17.5 (C) We believe that each of these challenges has a solution and propose that 5.4.1 and 5.4.2 be dealt with through systematic training and public education [during the pilot phase of ARV treatment]. There are many misunderstandings about ARVs that can be resolved through accurate public education. It is important that people understand that ARVs are only one aspect of the Framework Agreement, albeit an important part.
17.6 (C) The parties agree that there should be greater collaboration in terms of research between academic and medical institutions that identifies important areas for research where institutions can maximise the impact of their collaboration. For example, there is a need to conduct research into drug interactions between medicines used for HIV/AIDS by people who have other disabilities or illnesses requiring medication.
17.7 [To enter into negotiations with pharmaceutical companies and the use of compulsory licensing as part of the framework agreement. Voluntary licenses should be requested on essential anti-HIV medicines (for ARVs and opportunistic infections) immediately, as well as for key diagnostic tools;]
17.8 (G) Treatment Pilot Programme
17.8.1 [A treatment pilot programme would need to be developed by the Task Team. This plan would need to take cognizance of the varying capacities within the nine provinces, and the strength of the relevant health institutions within the country to provide highly active antiretroviral treatment. The treatment plan would need to focus on building the capacity of healthcare workers to manage antiretroviral treatment, and thus a training component would be important.]
17.8.2 [In terms if treatment regimens, it is proposed that the recent WHO recommendation for the treatment regimens is appropriate. These drugs are already registered within South Africa.]
17.8.3 (L) To give effect to this commitment, the constituencies now agree to the following:
(a) [To introduce a pilot phase to treatment, on the basis as set out hereunder;]
(b) [To commit, and further mobilize, financial resources from government, the private sector and the international community, and to commit and mobilize human resources from organized labour, communities, government and the business sector, and to set up a National Treatment Fund into which resources will be pooled;]
(c) Organised Labour commits to train 3 000 shop stewards to partake in support for people on treatment, which shall include home visits, promotion of openness in the workplace and counselling of fellow-workers to ensure that a caring environment is created;
(d) Organised Labour commits to support efforts to raise funds for the National Treatment Fund, from local and international donors;
(e) [The Business Sector commits to set aside, on a once-off basis, X% of payroll towards activities directed at combating HIV-AIDS;]
(f) [The Business Sector undertakes to provide treatment for people living with AIDS, through provision of treatment to employees working at companies employing more than 300 workers, and to contribute to the National Treatment Fund a sum of RXXX annually. [Nedlac parties to agree sum to be set;]
(g) [Government commits to supporting local production of anti-retroviral and other medication, and exporting such medication throughout southern Africa; ]
(h) [Government commits to underwriting and financing the phased programme of anti-retroviral provision, in partnership with donor agencies; and]
(i) Communities commit to social mobilization aimed at breaking down stigma, providing accurate information about treatment and creating a social climate that encourages adherence to treatment. [ADD].
18. THE ANTI-RETROVIRAL TREATMENT PILOT PHASE
18.1. (B) This will need considerable investigation. More detail on the exact nature of labour’s proposals on this score is required before any meaningful comments / proposals can be made.
18.2. (C) There is no question about the efficacy of anti-retroviral treatment in improving health, reducing opportunistic infections and prolonging life.
18.3. (L) To complement the programmes around prevention, and treatment of opportunistic infections, the parties agree to introduce a nationally co-ordinated anti-retroviral pilot, building on a partnership between government and civil society, and providing for public and private sector collaboration.
18.4. (L, C) To this end, the parties agree to a target of providing anti-retroviral treatment to a minimum of 100 000 persons who need it, in the pilot phase, by 1 December 2003.
18.5. (L, C) The parties further agree that the target will be allocated on the following basis:
18.6. provision by the public sector: a minimum of R50 000; distributed on the basis of at least two pilot sites per province, based on existing capacity, and AIDS prevalence;
18.7. provision by the private sector: a minimum of R50 000; with R30 000 provided through medical aid schemes, and a further R20 000 through treatment provided by larger companies;
(a) (C) Roughly this means targets of:
Western Cape 15,000
Northern Cape 2,000
Free State 5,000
North West 5,000
18.8. (L) The parties agree to the launch of a National Treatment Literacy Programme to underpin the pilot. To this end, organised labour and community organizations agree to raise R10m for this purpose, through National Big Walks, and other fund-raising activities.
18.9. (L) During the pilot phase, the parties commit to making the following resources available:
18.9.1 Government undertakes to set aside resources in the National Budget sufficient to provide anti-retroviral treatment for the targeted 50 000 persons in the pilot phase;
18.9.2 Government undertakes to ensure that there are no restrictions on the employment of additional health care personnel, to the extent required to make the pilot a success;
18.9.3 Organised labour undertakes to run an intensive education programme at the workplace in support of the pilot phase, and to mobilise resources on the basis set out above;
18.9.4 The Business Sector undertakes to finalise a ‘business plan’ to give effect to the commitment to provide anti-retroviral treatment to at least 50 000 persons through a combination of medical aid and large company provision, by 1 February 2000;
18.9.5 [Further commitments applicable to the business sector should be added here, including those related to support for production of anti retroviral drugs locally ];
18.9.6 Communities undertake [commitment to be added here];
18.10. (C) Government has already made a commitment to the universal right to treatment of opportunistic infections. However, as indicated above, this requires measures to ensure better drug supply to clinics, training of health professionals in accordance with existing policies, and systems for monitoring capacity, quality of care and access.
18.11. (C) No concrete commitment has yet been made by government with regard to access to antiretroviral treatments. This is despite recommendations made by the Department of Health’s November 2001 National Health Summit and the August 2002 HIV/AIDS summit. The Community constituency therefore proposes that by 01 December 2002 a special technical task team (made of constituency nominees) determine the location of two community anti-retroviral treatment sites per province according to:
8.11.1 existing capacity;
(9.1 The parties agree that a public-private sector prevention and treatment evaluation committee constantly monitor and evaluate results and outcomes of the NPTP.
9.2 The parties agree that the SANAC be primarily responsibility for monitoring progress against implementation.
9.3 The parties agree to strengthen the SA National AIDS Council (SANAC), and to this end support proposals that SANAC:
9.3.1 Be restructured to include representation on it by the Nedlac constituencies.
9.3.2 Be a functional body with professional Programme Directors at the helm, be answerable through a Management Council or Board of Governors, representing a broad range of Civil Society, health professionals and the HIV/AIDS cluster Ministries;
9.3.3 Have appropriate management structures, with clearly defined terms of reference;
9.3.4 Fulfil its mandate to increase inter-sectoral, national, provincial and community cooperation;
9.3.5 Be accountable and transparent; and
9.3.6 Establish the SANAC Trust Fund so that it can function.)
8.11.2 need (AIDS prevalence);
18.12. (C) The Community constituency proposes that labour, business and community should engage in community preparedness programmes that aim to provide treatment literacy, prevention information for people with HIV, and information on human rights as widely as possible, but initially particularly targeted at the treatment sites.
18.13. (C) The Community constituency recommends that a public-private sector treatment evaluation committee (composition to be discussed) constantly monitor and evaluate results and outcomes of this pilot phase.]